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Oakville Program Treatment Guide Vers.1.0 (November 2020) Page

© 2020 Australian Stuttering Research Centre

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The Oakville Program Treatment Guide November 2020 (Version 1.0)

Cheryl Andrews, Sue O’Brian, Natasha Trajkovski

This guide is written in four parts. Part One gives a brief overview of the Oakville Program along with information about its origins and for whom the treatment is suitable. Part Two describes and explains in more detail the major components involved in the implementation of the program. Part Three describes what typically happens on a week-by-week basis when speech pathologists implement the program with a parent and child. Part Four summarises the evidence for the program.

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PART ONE: INTRODUCTION ______________________________________________________

Qualified practitioner This guide is intended as a reference tool for use by speech pathologists during treatment. It is essential that a speech pathologist trains, guides, and supervises parents during the Oakville Program. The treatment is not designed to be administered by parents independent of this specialist support.

A behavioural treatment The Oakville Program is a treatment for children that aims to reduce stuttering. Parents do not change the family lifestyle in any way, apart from 1) encouraging the child to use syllable-timed speech (STS) and 2) presenting contingencies for the child’s stutter-free and stuttered speech. These activities occur during practice sessions and occasionally throughout the day. The child’s parents deliver the treatment in the child’s everyday environment. The ultimate aim of the treatment is to achieve normal speech rate and speech that does not sound unnatural in any way.

Syllable-timed speech (STS) Syllable-timed speech involves saying each syllable in time to a rhythmic beat. For example, “The chil-dren are play-ing on the tram-po-line.” “The kit-ten is drin-king its milk.” Typically, STS produces vowels of similar duration for each syllable. For young children, it can be useful to give STS a name, for example, “syllable talking”. STS is only used for a short period during this program in order to achieve periods of stutter-free speech. Emphasizing this short-term use of STS to the child aids compliance.

Contingencies The term “contingencies” refers to when parents give either verbal or non-verbal feedback to their child about their speech either after the child produces a period of stutter-free speech or after a stutter. The contingencies used in the Oakville Program are similar to those used in the Lidcombe Program;1 however, following stutter-free speech, there is no request for self-evaluation, and, following a stutter, a request is typically made for the child to repeat the stuttered word (or phrase containing the stuttered word) using STS. For example, a parent may say “Can you say ‘He is run-ning’ (parent using STS) again?” Parents provide contingencies during practice sessions and during everyday conversations. Praise is used far more frequently than correction.

Treatment overview At the beginning of treatment, the speech pathologist instructs the parent and child how to use STS using demonstration, imitation, and practice. Once the parent and child have learnt how to use STS with the speech pathologist, the child is encouraged to use STS in practice sessions and, later, occasionally during naturally occurring everyday conversations. Initially, STS practice sessions are encouraged 4-6 times per day for about 5-10 minutes each time. When this goal has been attained and there has been a drop in stuttering severity,



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contingencies for stutter-free speech and stuttering are introduced into the practice sessions and the number of practice sessions is reduced. As stuttering reduces further, STS is withdrawn and practice sessions reduce. More details about the specific procedures are given in later sections.

Treatment goals during Stage 1 and Stage 2 The Oakville Program is conducted in two stages. The treatment goal of Stage 1is for the child to speak with no stuttering or almost no stuttering in everyday conversations, and the goal of Stage 2 is for no stuttering or almost no stuttering to be sustained for a long time.

Measuring stuttering Regular measurement of children’s stuttering severity occurs throughout the program with a Severity Rating (SR) scale: 0 = no stuttering, 1 = extremely mild stuttering, and 9 = extremely severe stuttering. Parents, speech pathologists, and sometimes children, use the SR scale during the program.

Parent consultations Parents are responsible for implementing the treatment at home with their child each day. Parents initially consult with the speech pathologist weekly, either by clinic visit or by webcam. Consultations typically last around 45 minutes. Consultations reduce to fortnightly when specific criteria have been met. During each consultation, the speech pathologist instructs the parent how to do the treatment and ensures that it is being done properly. Later in this treatment guide, an outline of the specific criteria for reducing the frequency of visits is given as well as suggestions as to what should occur during each consultation and in what order.

Origins of the treatment According to one model,2 the speech motor systems of those who stutter may be susceptible to variations in linguistic stress, and these variations can trigger moments of stuttering. Saying each syllable in time to a rhythmic beat reduces these variations and allows the child to produce and practise stutter-free speech. An initial trial of STS with school-age children3 showed that practice of STS could reduce stuttering significantly during the first 6 weeks of treatment. However, practice of STS alone was unable to maintain these reductions, and child non-compliance became an issue. Parent contingencies for stutter-free speech, and for stuttering, were added to deal with these two issues.4

Indications for using the Oakville Program The Oakville Program is most suited to children who have more severe stuttering or previous treatment failure with the Lidcombe Program.1 It is more likely to be used with children over 6 years of age although some of these children, especially those with mild stuttering, may still respond well to the Lidcombe Program.

Resource materials On the Australian Stuttering Research Centre website, there are a number of resources to help speech pathologists implement the Oakville Program (https://www.uts.edu.au/asrc/resources/oakville-program):

(1) A downloadable SR chart (Child Stuttering Severity Chart (eForm and PDF versions) for parents and speech pathologists. This SR chart is reproduced in the Appendix of this guide.

(2) A model of STS (Syllable-timed Speech Training Model) spoken by the first author as it should be used throughout the program.

(3) Four video demonstrations of a speech pathologist teaching STS to a child in imitation, short sentences, long answers, and conversation.

(4) An activity guide (Stuttering Treatment Activity Guide) containing a list of activities that can be used with a child to practise syllable talking.

https://www.uts.edu.au/asrc/resources/oakville-program



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PART TWO: OAKVILLE PROGRAM COMPONENTS ______________________________________________________________________________________________

This part of the guide describes and explains the individual components that are taught to the parent and child during the Oakville Program. They are presented in roughly the order they might be used in the clinic, although there will be some overlap between all of them. The way they are implemented in a week-by-week basis is presented in Part Three of this guide.

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Measurement: the stuttering severity rating scale _________________________________________________________________________________

Overview The following section contains general information about stuttering severity ratings, their importance and use generally, and the training required. “PART THREE: CLINICAL CONSULTATIONS” on page 11, contains specific information about how to integrate this training into weekly consultations with the parent.

Purpose of severity ratings Severity ratings (SRs) are used to measure the child’s stuttering during each consultation and in their everyday speaking situations. The simplicity of SRs makes them a quick and effective way for speech pathologists and parents to communicate with each other about a child’s stuttering severity. They enable treatment goals to be evaluated constantly. If progress is not satisfactory, then SR scores will alert the speech pathologist and the problem can be addressed. Such problem solving, and subsequent decision making, is a routine part of the program, and much of it centres on SRs. It is useful if speech pathologists explain the importance of SRs during the first consultation and reiterate this throughout the course of the treatment. Taking time each week to discuss and problem-solve around the child’s SR scores from the previous week is a major contributor to parents continuing to collect and report daily SR scores.

Treatment goals determined by severity ratings Parents assign a SR to their child’s speech each day, and the speech pathologist and parent assign a SR for a baseline sample taken at each treatment consultation. Long term treatment goals, weekly treatment decision-making, and progression through the program are all based on these scores.

A flexible measurement Severity ratings are a flexible way to measure stuttering severity. Each day, parents record a SR for the whole day to reflect their child’s typical stuttering severity for the day. In other words, they record the score they would have assigned for the majority of the day. Parents may not always hear their child talking all day, such as when they are at pre-school or school. In such cases, parents assign a SR based only on the speech they hear during the day.

Variations of the SR procedure can be used if the speech pathologist thinks it would be helpful. For example, one possible variation is to assign one SR for the morning and one for the afternoon. Speech pathologists may wish parents to use supplementary SRs for particular speaking situations that occur each day, such as dinner, bath time, and shopping. Another option is for the parent to record a highest and lowest SR for each day. These SRs are recorded in addition to the daily typical SR.

Valid and reliable parent severity ratings are essential Research shows that parents are able to assign SRs that agree with those of a speech pathologist.5 It is essential for speech pathologists to ensure that this agreement occurs, as treatment progression and problem-solving rely on the parent and speech pathologist having a reliable means of communication. However, speech pathologists also need to be aware that the child’s speech during the consultation, and hence their SR during the consultation, may not accord with parent scores from the child’s everyday conversations. For various reasons, such as child shyness, reduced amount of conversational speech, or lack of variation in activities during the consultation, this SR may often be different from the parent report of SRs around the home environment.



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Parent SR training The parent is trained to use SRs either at assessment or during the first consultation. Training begins with the speech pathologist explaining the reason for collecting measures and then explaining the scale and its end points. The parent or the speech pathologist, or both, talk with the child for a few minutes until the child displays a reasonably representative amount of speech and stuttering. After a few minutes, the speech pathologist asks the parent to assign a SR to the speech sample. The speech pathologist indicates whether that is an appropriate score and, if necessary, suggests a different score.

This score is documented in the child’s file. As noted above, speech pathologists need to be aware that this within clinic score is not necessarily representative of the child’s everyday conversational stuttering severity score. Also, if the child’s stuttering increases significantly during the remainder of the session, possibly due to more representative speech being elicited, the latter score would be documented.

All subsequent consultations begin with a child conversation. The parent then assigns a SR score, and the speech pathologist either confirms that the score is appropriate or provides corrective feedback. The speech pathologist’s judgement, based on clinical experience, is used as the yardstick for SR scores. Acceptable agreement is when the parent SR is within one scale value of, or identical to, the speech pathologist SR. It is desirable, however, during the later stages of treatment, for parent and speech pathologist SR scores to be identical. This is because, during those later stages of treatment, children’s severity will be at the lower end of the severity range, and there will be less margin for error with clinical use of the scale.

Another more time efficient and valid speech sampling method—particularly early on in treatment—is for parents to audio or video record the child during one or more conversations of everyday life. This will provide a much more realistic measure of the child’s stuttering severity. In this scenario, the speech pathologist and parent will listen to the recording together and consider a SR score at the start of the consultation. This method has the advantage of being able to scan quickly though a long and representative set of recordings of the child’s speech.

Discussion of the different types of stuttering in the child’s speech is a useful part of a consultation. This is because clinical improvement, in terms of reduced stuttering, is often accompanied by a change in the type of stuttering a child presents with. One method of classifying stuttering behaviours6 uses three main categories: repeated movements, fixed postures, and extraneous behaviours. A moment of stuttering may comprise one or more of these behaviours.

Documenting severity ratings Parents may produce hand-written SRs each week for the consultation or they can use an e-version of the form accessible on their computer or phone. Both PDF and eForm versions of the “Child Stuttering Severity Chart” template can be found on the ASRC website (https://www.uts.edu.au/asrc/resources/oakville-program). A disadvantage of the parent producing a weekly collection of SRs is that the speech pathologist cannot monitor whether parents are recording a score at the end of each day. Sometimes, parents are not compliant with that instruction and will wait a few days to record scores. This can lead to inaccurate scores.

Another option is for parents to email the SR form or send photos of it to the speech pathologist, either throughout the week or prior to each consultation. These options can also be used for the speech pathologist to obtain SRs on occasions when parents are unable to attend a clinic consultation.

Training older children It is useful to also train older children (around 9 years and above) to collect and document their own severity ratings. The training will be done in the same manner as training for the parents and will typically begin during the second consultation. Children and parents will document their ratings on separate forms. It is not uncommon for a child’s ratings to differ from that of their parent. The information gained from the child evaluating stuttering severity at school and with friends can add valuable information to discussions regarding progress. Sometimes older children can show interest in, and compliance with, taking their own SRs at the beginning of treatment but later lose interest. Whether to persist with the child’s documentation of their SRs is decided on a case by case basis.

The bilingual child When the child speaks two or more languages, it is important to ask the parent whether the child stutters more in one language than in the other and to regularly report SRs for both languages. This information will feed into a decision about whether to include one or both languages in treatment. Identifying stuttering and assigning SRs is not difficult in a language in which the speech pathologist is not fluent, even if the content is unknown. If the child tends to stutter more in the language of treatment (typically English), then usually gains




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will generalise to the other language. On the other hand, if the child stutters more in another language, it will be important once the parent understands the main concepts of treatment in English to try to also do treatment in the other language.

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Syllable-timed Speech Practice _____________________________________________________

This section about STS practice contains detailed conceptual information about the teaching and practice of STS with the parent and child. However, the way it is introduced to the parent and child on a week-by-week basis is covered in the “PART THREE: CLINICAL CONSULTATIONS” section on page 11.

Hierarchy of STS teaching The treatment begins with the speech pathologist teaching the child how to do STS while the parent watches. Age-appropriate books, for example, “Where’s Wally” for older children and Usborne picture books for younger children are useful for stimulating speech. STS is spoken like this:

• The dog is run-ning; • The kit-ten is li-cking its paws • The wo-man is ri-ding a brown horse

STS is introduced initially using imitation, with short sentences and slowed rate. Both imitation and slowed rate assist the child to achieve correct production of the speech pattern and are important teaching techniques. However, it is also important to use and encourage normal volume, pitch, and intonation. Each syllable should be joined to the next one in a smooth flowing manner (legato) rather than punched out with each syllable separated from the next one (staccato). On the Australian Stuttering Research Centre website there is a downloadable audio Syllable-timed Speech Training Model (https://www.uts.edu.au/asrc/resources/oakville-program) for parents and speech pathologists to use. There are also four video demonstrations (https://www.uts.edu.au/asrc/resources/oakville-program) of a speech pathologist teaching STS to a child in imitation, short sentences, long answers, and conversation.

When the child can sustain STS for a number of short utterances, the child moves to simple conversation. Picture books or conversations about play activities can be used as stimulus materials. Some children may need intermediate steps, such as picture description or asking questions, to elicit short answers. These steps reduce the cognitive load and help them to concentrate on using the new STS pattern more successfully. Some children may also require imitation for much longer than others, especially those with concomitant disorders, such as attention deficit hyperactivity disorder, developmental delay, or autism spectrum disorder. Progression from short utterances to simple conversation may take place quite quickly (within a week) or over several weeks, depending on the child’s ability to imitate and maintain use of the technique. Children with issues additional to stuttering typically take longer. No programmed instruction (predetermined performance-contingent hierarchical steps) is used when the STS pattern is taught.

It can be useful for the speech pathologist to make a recording of themself and the child using the STS pattern correctly when talking together. This reference model helps to stop the child’s or parent’s technique from morphing into normal speech or moving towards staccato-sounding speech when practising at home together.

Home STS practice sessions When the child and the parent demonstrate proficient use of STS with the speech pathologist, practice sessions begin at home. The definition of a practice session is when a time is specifically set aside for the parent and child to use STS together. This may be in a naturally occurring conversation if the child is able to do this. However, early in the treatment, it might be a time set aside for imitation or use of STS in short sentences. The goal is for the child to use STS for 5-10 minutes at a time during 4-6 practice sessions spread across the day. Practice can be done anywhere a parent and child are together and able to concentrate on the task. Examples of everyday naturally occurring treatment situations would be talking at the dinner table, reading a book, engaging in a play activity together (for example, playing with Lego), preparing meals, hanging out the washing, and driving in the car. The parent also speaks in STS during these practice times.

During practice sessions, the child should be trying to maintain STS for most of the time. Occasional gentle prompts for STS, for example, “You are doing really well, but see if you can do a little bit more syllable talking” can be used if needed. If the parent slows down their own rate of speech while using STS, this can signal to the child to use STS and avoids stopping the flow of conversation or requesting a correction. If the child is unable to maintain STS in conversation, then there may be a need to go back to easier practice tasks,






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such as imitation or short sentences, for a while, as well as the parent slowing down when modelling the rate of speech. Sometimes more focused practice activities (for example, looking at a book or photos together) versus practice “on the go” in everyday activities may help too. Some children may need to rely on imitation for some time but improvement can still be made in such circumstances. Parents can encourage and reinforce the child’s use of STS with praise (“Great syllables! Keep talking like that!”), or they can request that the child self-evaluate for use of STS (“Was that great syllable talking?”).

Some essential things about STS practice

How STS should sound

STS is initially taught with slowed speech rate, then progresses to a near normal speech rate. However, children may need to drop back to a slower rate at times if they find STS difficult to maintain. When using STS, it is essential to ensure both parent and child use normal volume, normal pitch, and normal intonation and to link the syllables together. Each syllable should be evenly stressed.

Be sure parents are demonstrating and eliciting STS correctly & consistently

Speech pathologists need to be sure that parents are demonstrating and eliciting STS correctly according to their instructions. At each consultation, parents demonstrate how they have been practising STS with the child during the previous week, and the speech pathologist gives them feedback. Alternatively, parents may audio or video record examples of themselves doing STS practice sessions and play them to the speech pathologist during the consultation. The speech pathologist will also engage the child in an STS practice session to demonstrate treatment for the parent to watch. The order of parent or speech pathologist demonstration is not critical, but it is determined by discussion and problem-solving and typically changes as the parent and child become more skilled with the STS speech pattern. It is not a static process but a fluid one.

Practice sessions are a positive experience for the child

Practice sessions must be a positive experience for the child. It is essential to identify when they are not a positive experience. Activities need to be varied to avoid boredom. Speech pathologists should also watch out for parent over-correction. Neither STS nor a request for self-evaluation should be used as a correction for stuttering during STS practice sessions.

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Prompts ___________________________________

When the child can maintain STS for most of the practice session, and 4-6 practice sessions are being done each day, prompts are introduced. These are used outside of practice sessions. A prompt involves the parent encouraging the child to use STS for a few sentences during a naturally occurring everyday conversation. At other times during the day, it is useful for the parent to speak using STS for a few sentences and allow the child to join in. While there is no requirement for the child to use STS at these times, they tend to use it voluntarily. It is important that the timing and frequency of prompts are discussed with the parent. Generally, no more than one per hour would be recommended, and only if the child tolerates them. They should also only be provided in “comfortable” environments, for example, with the family, not in front of friends or peers. At this stage of the program, prompts for STS should never be used as a response to the child’s stuttering.

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Contingencies for stutter-free speech and stuttering ______________________________________________________________________________________

The following sections give information about the nature and purpose of contingencies for stutter-free speech, and stuttering generally, when used within the Oakville Program. However, the timing and the way contingencies are introduced to the parent and child on a week-by-week basis are covered in the section “Hybrid practice sessions” which follows immediately afterwards (page 8).

Overview Parents are taught to provide contingencies for the child’s stutter-free speech and stuttering. These contingencies may be verbal or non-verbal. Contingencies are introduced only when STS has been mastered and the child is routinely using it during STS practice sessions.



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Specifically, contingencies are introduced into the practice sessions when (1) the child is compliant with the 4–6 daily STS practice sessions and (2) a significant drop in stuttering severity has been achieved outside the practice sessions. It is difficult to prescribe a “significant” drop in severity because it will depend on the child’s initial stuttering severity. Speech pathologist skill will be needed to determine this. The use of contingencies occurs first during structured STS practice sessions with the speech pathologist and parent, and then later during naturally occurring everyday conversations.

The purpose of introducing the contingencies is to help maintain general compliance with treatment and to further reduce stuttering. Some children become bored with STS practice quite quickly, and compliance starts to become an issue, so it is important to try to introduce contingencies before this happens. Once contingencies have been introduced, practice sessions reduce to around three per day, typically around 10–15 minutes in duration.

Contingencies are mostly given in response to stutter-free speech. The assumption is that the use of STS during the practice sessions will lead to mostly stutter-free speech during these sessions, and this stutter-free speech will be maintained even after STS is faded out during the session. Therefore, very few contingencies for stuttering should be required.

Verbal contingencies for stutter-free speech involve praising or acknowledging the response, such as “that was great talking” and “that was smooth.” They need to be genuine, varied, and in keeping with individual parent style. Verbal contingencies for stuttering mainly involve requesting self-correction by the child using STS, for example, “Can you say [stuttered word or phrase] again?” If it is a single syllable word, it is appropriate to add the next few words using STS in the request for correction. If the speech pathologist or parent models using STS during the request, the child will normally also use STS for the correction. These contingencies should be used very sparingly and should not be at all punitive or evaluative. The speech pathologist monitors all aspects of these contingencies during consultations.

Some important things about contingencies

Teach contingencies for stutter-free speech first

The speech pathologist doesn’t teach the parent how to give all contingencies at once. Normally, they would demonstrate and teach parents how to give contingencies for stutter-free speech during practice sessions first so that the child can become comfortable with the feedback. Later, the speech pathologist demonstrates and teaches the parent how to give contingencies for stuttered speech when they are sure the child is ready for it. It makes clinical sense to introduce contingencies for stutter-free speech before contingencies for stuttering because the former are inherently positive.

Be sure parents are using contingencies correctly

The speech pathologist needs to be sure that the parent is using contingencies correctly according to their instructions. At each clinic visit, parents demonstrate how they have been giving the contingencies to their child during the previous week. Parents may audio or video record examples of themselves providing contingencies during practice sessions and play them to the speech pathologist during the clinic visit. In either event, the speech pathologist gives constructive feedback and then watches parents give contingencies as they take account of that feedback. Parents delivering contingencies incorrectly is a common reason that children do not progress as expected through Stage 1. This problem can persist and undermine the treatment process if the speech pathologist does not detect it by direct observation of parents.

Contingencies are for unambiguous stuttering moments

Feedback for stuttering will only be needed infrequently because there should be little stuttering when speech in everyday conversations follows practice of STS. Such feedback is only given for unambiguous stuttering moments. If parents have any doubt about whether a disfluency is actually a stutter, then they should not use a contingency. Giving contingencies for ambiguous disfluencies normally only becomes an issue towards the end of Stage 1 when children have SR 0–1; that is, when there is no stuttering or there is only extremely mild stuttering during most days.

Contingencies are a positive experience for the child

All contingencies, whether for stutter-free or stuttered speech, must be a positive experience for the child. They must not be constant, intensive, or invasive. The child needs to experience the contingencies as enjoyable and sincere. For some parents, it may be necessary to introduce the contingencies slowly and carefully in order to be sure that the child is receiving supportive and enjoyable contingencies. There should always be far more contingencies for stutter-free speech than for stuttered speech.



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Have parents give only as many contingencies as are needed

Contingencies are introduced only after the child has been consistently practising STS during practice sessions for a while (See “Hybrid practice sessions”, below, for details). Therefore, stuttering will already be mostly under control during these sessions, and few stutters are likely to occur. Therefore, there will be relatively few, if any, opportunities to give feedback for stutters. Feedback will focus mostly on praise for stutter-free speech, but even this will be minimal.

Contingencies are accurate

It is essential that the speech pathologist is satisfied that the parent can present contingencies accurately in the clinic with the speech pathologist before they are attempted at home. The speech pathologist needs to be sure that parents can distinguish between unambiguous stuttering moments and stutter-free speech. It is also essential that contingencies, when given, are presented immediately after periods of stutter-free speech and stuttering moments. Delayed or inaccurate contingencies are unlikely to be effective. At each clinic visit the speech pathologist needs to observe, either during clinic real time or from recordings, parents providing immediate and accurate contingencies.

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Hybrid practice sessions ___________________________________________

This section describes how the contingencies outlined above are first introduced to the parent and child in the Oakville Program. This occurs during hybrid practice sessions. Before introducing the contingencies, an age-appropriate explanation should be given to the child about what is about to change. For example, the child can be told that the practice session will now change and that it will no longer be just syllable talking but will now also include natural/normal/smooth speaking (whichever terminology makes sense to the child).

Instead of a practice session consisting of 5-10 minutes of pure STS practice, the session will initially be divided into two halves. The first half will consist of the familiar STS practice, but, during the second half of the practice session, the child will be encouraged to talk naturally. The speech pathologist first introduces and demonstrates the transition to natural speech with the child. The parent then attempts to do the same with the child. Finally, the speech pathologist provides feedback about the parent attempt. Typically, during the second half of the session, the speech pathologist or parent will just begin talking without STS, and the child should be allowed to drop out of STS naturally. Sometimes the child will continue to use STS after being instructed to use natural speech. It is best to avoid prompting natural speech, and just let the child drop out of STS speech in his own time.

During the second half of the practice session, the contingencies for stuttered and stutter-free speech described above will be introduced. Generalisation of stutter-free speech from the STS practice in the first half of the session usually leads to mostly stutter-free speech in the second half. Therefore, contingencies will be infrequent and mostly praise directed at reinforcing the stutter-free speech the child produces. The speech pathologist will demonstrate this first, then the parent will be asked to demonstrate praising the child during the natural talking part of session. In later sessions, occasional contingencies for stuttering may be given if it occurs. A contingency for stuttering will usually be in the form of a request to repeat the word or phrase using STS (as described above) but may also just be a request to stop and start again.

Over time, the dividing line between how much time is spent practising STS and how much time is spent using natural speech with contingencies will slide. Initially time will roughly be allocated 50% (around 5 minutes) to each activity. As beyond clinic SRs continue to drop, less time will be spent on STS practice and more time will be spent using natural speech – 50/50, then 40/60, then 30/70, and so on. The ultimate goal is obviously to reduce the need for STS practice altogether.

The movement of the dividing line will be determined by the child’s progress. As long as the child is evidencing high SRs or a slow downward trend, the dividing line will remain 50/50 or move very slowly as it is assumed that the child still needs to use STS to achieve fluency. For some children, generalisation of STS occurs quite quickly and little time needs to be spent using STS in practice sessions. If stutters increase in the second part of the session, STS practice will be increased to 80/20 or 70/30. Manipulating the length of the child’s utterance, as frequently occurs in the Lidcombe Program, is, therefore, unnecessary.

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Contingencies during everyday conversations _____________________________________________________________________________



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What they are

When the speech pathologist feels it to be appropriate, verbal and non-verbal contingencies are introduced into everyday conversations with the child. The natural conversations of everyday childhood life are never modified to optimise the occurrence of stutter-free speech. Instead, parents take advantage of naturally occurring periods of reduced stuttering during each day to present contingencies. Examples of everyday conversations with children, during which parents typically give contingencies, typically occur during food preparation, at meal times, in the bath, on the way to school, in the park, and whilst shopping. As with contingencies during practice sessions, they can be supplemented with nonverbal contingencies if the speech pathologist thinks that they would be helpful. Non-verbal contingencies may take the form of a “high five!” or a token reward.

When they are introduced

Verbal contingencies during everyday conversations are introduced when the speech pathologist observes that the parent is consistently giving verbal contingencies safely and correctly during practice sessions.

Transitioning from structured practice sessions into everyday conversations

For a period, parents give feedback during practice sessions and during everyday conversations. Eventually, feedback during everyday conversations completely replaces feedback during daily practice sessions. However, the withdrawal of practice sessions should be done extremely cautiously, as practising stutter-free speech in sessions assists in the maintenance of stutter-free speech.

The speech pathologist may decide that this transition should not be completed until as late as some time during Stage 2. The transition is a flexible process. During the period when parents are providing verbal contingencies in practice sessions and everyday conversations, the speech pathologist may recommend several changes to the number and duration of practice sessions. An example would be changing from one practice session each day to one practice session every second day. Similarly, during this transitional period, the speech pathologist may direct many changes to the number and type of verbal contingencies that parents give during everyday conversations. At times, it may also be necessary to reintroduce STS practice.

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Rewards ___________________________________

Compliance may be an issue for some children. In such cases, it may be appropriate to reward the child specifically for compliance. Rewards are optional and individualised for each child. Sticker charts, tokens earned towards an ultimate goal, or activity-based rewards may be designed to suit the child’s age and interests. Praise for the child’s use of STS should occur occasionally, both within and outside of practice sessions. Compliance should not be confused with a child’s inability to sustain STS use. In such cases, slowed speech rate and praise are more appropriate.

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Overview of Stage 1 ___________________________________

The Oakville Program consists of two stages: Stage 1 and Stage 2. At the beginning of Stage 1, the parent and child initially consult with the speech pathologist weekly, either in the clinic or by webcam. When the child can maintain STS for the 5-10 minute practice sessions and is complying with practice sessions 4-6 times per day, prompts to use occasional STS sentences in everyday conversations are introduced, and consultations move to fortnightly. When contingencies are introduced into the practice sessions, the number of these sessions reduces to a minimum of three, however they are typically 10-15 minutes in duration. During the latter weeks of Stage 1, the parent slowly withdraws the last of the STS practice sessions, providing that it can be done without an increase in stuttering. As severity ratings decrease to less than 2, the number of sessions reduce to 2 per day. Just one practice session per day is required for several weeks before entering Stage 2. STS rarely remains part of the treatment focus on entry into Stage 2. The child moves into Stage 2 when the following two criteria have been met for two consecutive fortnightly consultations:

(1) Speech pathologist SR of 0 or 1 during the consultation

(2) Daily parent typical SRs of 0-1 during the week preceding the consultation, with at least four of those seven SRs being 0.

Pre-school children are typically able to meet these criteria for entry to Stage 2 and some school-age children may too. However, the stuttering of children with a history of previously unsuccessful treatment often proves



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more intractable. In such cases, it is appropriate to continue to work until low levels of stuttering are maintained, and altered criteria are established. A minimum requirement during Stage 2 is for parents to document SRs during the week preceding the consultation. However, the speech pathologist may request parents document SRs more often.

___________________________________

Overview of Stage 2 ___________________________________

The purpose of Stage 2 Stage 2 serves three purposes: (1) to withdraw practice sessions; (2) to maintain the absence or low level of stuttering that was attained during Stage 1; and (3) to ensure parents understand how to monitor and manage any increase that may occur in their child’s stuttering, reintroducing STS practice if needed.

Systematic withdrawal of practice sessions During Stage 2, the speech pathologist makes suggestions for the speed and timing of the withdrawal of practice sessions although occasional practice sessions are typically recommended for a few months. Prompting for STS may be used intermittently, but parents should avoid prompting for STS contingent on stuttering, unless stuttering is very infrequent. Decisions about the timing and rate of withdrawal of practice sessions are based on the child’s SRs and after discussion with the parent.

Empowering the parent Parents should be taught to problem-solve and deal with any increases in stuttering in the first instance. If stuttering increases minimally—to SRs of 1 or 2—the parent should be taught to reintroduce a practice session daily until the SRs reach criterion levels again. Practice sessions may need to include a minimal amount of STS practice, for example, 1-minute STS and 9 minutes natural speech with contingencies.

Parents should be encouraged to monitor for such an increase and to attempt to control it themselves before coming back to treatment consultations. In this manner, significant relapse is less likely to happen. However, if SRs increase substantially, or do not respond to reintroduction of practice sessions, parents should be encouraged to contact the speech pathologist for advice prior to the next scheduled Stage 2 consultation.

Performance contingent maintenance A performance-contingent maintenance schedule applied to stuttering treatment, and its potential benefits, have been documented.7 Performance-contingent maintenance means that the parent and child consult with the speech pathologist less frequently, provided that treatment targets are maintained; for example, four consultations 4 weeks apart, then two consultations 8 weeks apart, and, finally, one or two consultations 12 weeks apart. The schedule normally takes a year or more.

A common Stage 2 problem When children complete Stage 1 and there is no stuttering or nearly no stuttering, parents or speech pathologists, or both, can become complacent and not follow through with the prescribed Stage 2 maintenance program. This creates a serious risk that relapse will occur. It is important for the speech pathologist to ensure that parents are fully aware of the importance of a performance-contingent maintenance schedule and the risks if it is not followed.



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__________________________________________________________________________________

PART THREE: CLINICAL CONSULTATIONS __________________________________________________________________________________

Early Stage 1 consultations: focus on STS practice During the first part of Stage 1, the parent and child consult with the speech pathologist once per week. Each consultation is typically around 45 minutes. Once the STS practice is mastered, that is, the child is compliant with 4-6 practice sessions daily, consultations reduce to fortnightly. The following events normally occur during a consultation:

(1) Child conversation

The parent or the speech pathologist, or both, converse with the child until the extent of stuttering, if any, is apparent. Alternatively, the parent and speech pathologist listen to a recording or a selection of recordings of the child conversing during everyday life.

(2) Check parent SR

The speech pathologist and parent discuss a SR using procedures outlined previously (see “Parent SR training,” page 3). The speech pathologist documents a SR. Speech pathologists need to be mindful that a within-clinic SR is not necessarily representative of the child’s speech in his everyday activities.

(3) Discussion of progress since last consultation

The parent reports the child’s SR scores for each day of the previous week and the number, duration, and success of daily STS practice sessions. The speech pathologist then uses this information to focus an in-depth discussion of severity and treatment responsiveness from the previous week. Discussion topics normally include the following:

• When practice sessions were planned, did they occur as planned? How often and for how long?

• When during the day did the practice sessions occur? • What activity were the child and parent involved in during practice sessions? • Was STS practised in imitation or conversational speech? • Was the child able to sustain STS throughout the practice session? • How much was the child using STS during the practice session? • Did the parent use prompts for STS? How often? With what result? • Did the parent think anything did or did not work particularly well

during the week? • What was the relationship between stuttering severity and STS practice? • Did any activities appear to trigger an increase in stuttering? • Did the child enjoy, and was the child compliant with, the practice sessions?

(4) Speech pathologist and parent demonstrate an STS practice session

It is important during each consultation for both the speech pathologist and the parent to demonstrate STS practice with the child, as each serves a different purpose. The speech pathologist demonstrates with the child in order to reinforce to the parent the correct way to do the treatment. This can reassure the less confident parent that what they are doing is correct. It can also model the best procedures for the less competent parent who is having difficulty with the structure of practice sessions. It directs the changes that need to be made. Finally, it empowers the parent with more information.

It is equally important for the parent to demonstrate how they have been conducting the practice sessions with the child at home. This may be done live during the consultation, or the parent may bring in a recording of a session done at home, or both. This enables the speech pathologist to see how well the parent has interpreted the instruction given to them as well as how well the parent has been able to structure and conduct the sessions at home. This information is essential for speech pathologists and parents to engage in problem-solving each week.

Whether the speech pathologist or the parent demonstrates first will depend on a number of factors, including the stage of treatment, the behaviour and cooperation of the child, the confidence of the parent, and the discussion of progress during the previous week. Regardless of the order of demonstration, the fact that both



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the speech pathologist and the parent demonstrate also allows the child to get more practice using STS with different people.

(5) Parent and speech pathologist discuss issues with the conduct or scheduling of STS practice sessions

During and subsequent to the demonstration of the STS practice sessions, the speech pathologist and parent discuss any issues which become apparent with the scheduling, conduct, or structuring of the practice sessions. If the recommended procedures are not able to be followed, the speech pathologist and parent discuss the reasons and solutions for this.

(6) Planning treatment changes for the coming week.

The parent and speech pathologist discuss changes to procedures (for example, practice sessions or prompts) for the coming week and activities to use during practice sessions. The speech pathologist may demonstrate to the parent any changes to the treatment procedures for the coming week. The parent may also demonstrate the changed procedures if the child is compliant with this. Points 4 and 5 (above) and this point (6) are not prescriptive in terms of the order of the procedures, and often they will occur simultaneously. The important point is that the speech pathologist and parent, together, discuss and problem-solve any issues to do with implementation of the STS practice sessions, prompts, or child compliance that are uncovered during the session. The speech pathologist will use opportunities for further teaching and demonstration as required.

(7) Concluding the consultation

The speech pathologist concludes the consultation by summarising the plan for the coming week. It is extremely important for the speech pathologist to encourage the parent to raise any further matters for discussion.

Later Stage 1 consultations: Hybrid sessions (STS practice and contingencies) Contingencies are introduced into practice sessions when 1) the child is compliant with the 4-6 daily STS practice sessions and 2) a significant drop in severity has been achieved. See “Contingencies for stutter-free speech and stuttering”, page 6, for more details. Most often, the decrease in stuttering takes place within about 4-6 weeks of beginning treatment. At this stage, fortnightly sessions in response to compliance with STS practice will probably have already begun. Once contingencies are introduced, some of the events that normally occur during a consultation change slightly from those described above. These are outlined below:


As above for Early Stage 1 consultations (page 10).

(2) Check parent SR



The parent reports the child’s SR scores for each day of the previous week. The parent also reports the number of hybrid practice sessions undertaken each day; the ratio of STS to normal speech during the sessions; and the success, in terms of stuttering reduction, of each practice session. The speech pathologist then uses this information to focus an in-depth discussion of severity and treatment responsiveness from the previous week. Discussion topics could include the following:

• When practice sessions were planned, did they occur as planned? How often and for how long?

• Did the child enjoy, and was the child compliant with, the practice sessions? • What was the ratio of time spent practising STS compared with normal speech

using contingencies • When during the day did the practice sessions occur? • What activity were the child and parent involved in during practice sessions? • Was STS practised in imitation or conversational speech? • Did the parent use prompts for STS? How often? With what result? • What verbal contingencies were used during practice sessions and/or everyday

conversations? • How frequently did the parent give verbal contingencies during everyday

conversations? • How well did the child tolerate the verbal contingencies?



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• What were the child and parent doing at the time of verbal contingencies during everyday conversations?

• Did the parent think anything did or did not work particularly well during the week?

• Did any activities appear to trigger an increase in stuttering?

(4) Speech pathologist and parent demonstrate a hybrid practice session

It is important during each consultation for both the speech pathologist and the parent to demonstrate treatment in a hybrid practice session with the child. Both the parent and the speech pathologist will individually conduct STS for the first half of the practice session; then the speech pathologist and then the parent will each demonstrate the giving of contingencies during the normal speech during the second half of the practice session. Over time, and as the parent becomes more proficient at implementing the treatment, the parent will conduct both parts of treatment while the speech pathologist will only demonstrate if needed.

(5) Parent and speech pathologist discuss issues with the conduct or scheduling of the hybrid practice sessions

During and subsequent to the demonstration of the hybrid practice sessions, the speech pathologist and parent discuss any issues which become apparent with the scheduling, conduct, or structuring of the practice sessions. If the recommended procedures are not able to be followed, the speech pathologist and parent discuss the reasons and solutions for this.

(6) Planning treatment changes for the coming week.


(7) Concluding the consultation


Stage 2 consultations

A typical Stage 2 consultation lasts around 30 minutes. The following events normally occur during a consultation:



(2) Check parent SR



The speech pathologist and parent discuss the extent to which the child’s clinic SR and weekly SRs have been typical of all weeks since the last consultation. They then discuss general progress since the last consultation. Topics may include, but are not limited to,

• The stability of the stuttering reduction • The duration and degree of any fluctuations • The number of practice sessions or the need to reintroduce any practice sessions • The use and effectiveness of prompts • Any activities that prompted more stuttering

Withdrawal of practice occurs as soon as possible once low SRs are maintained.

The parent continues to collect daily SRs for at least the week prior to each consultation. If the child meets the criterion treatment goals (see “Overview of Stage 1”, page 9), the speech pathologist arranges progression to the next step in the performance contingent Stage 2 schedule. If the child does not meet those goals, progress is not recommended. Instead, depending on the child’s stuttering severity and the parent’s ability to deal with stuttering fluctuations, the speech pathologist either 1) schedules an appointment for the next week, or the week after, and makes recommendations regarding management for the child’s increased stuttering; 2) schedules a return to an earlier stage of the sequence of Stage 2 clinic consultations; or, 3) on rare occasions, returns the child to Stage 1.

Stage 2 continues until the child has sustained minimal stuttering for around a year. Subsequent to the conclusion of Stage 2, parents are advised to contact the speech pathologist if any relapse occurs that cannot be managed by short-term reintroduction of STS practice.



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__________________________________________________________________________________________________

PART FOUR: THE OAKVILLE PROGRAM EVIDENCE BASE AT NOVEMBER 2020 __________________________________________________________________________________________________

There are currently only two clinical trials involving the Oakville Program. One trial involved 91 pre-school children aged up to 5 years 11 months.8 The trial was a three-arm randomised controlled trial with the Lidcombe Program as the control arm and the Westmead Program and the Oakville Program as the two experimental arms. There were blinded outcome assessments at 9 months post-randomisation. There was no difference in percentage syllables stuttered (%SS) scores between groups at 9 months post-randomisation. A major limitation of this study, however, was the large drop-out rate of around 43% for both STS treatments.

Subsequent to a preliminary trial,3 a nonrandomised trial recruited 22 children aged 6–11 years.4 Three children withdrew from treatment. Twelve months post-treatment, the remaining 19 children showed a group mean reduction in stuttering of 77%, although there was considerable variation in response. Many of the children also had comorbid speech and language problems.



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_______________________________________________

ACKNOWLEDGEMENTS _______________________________________________

The authors of this guide wish to acknowledge the valuable input of the following people in reading and offering comments on early drafts of this guide: Mark Onslow, Damien Liu-Brennan, Monique Jones, Sarah Byles, Caitlin Richards, and Ann Packman.



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_____________________________________________________________________________

Appendix One: Child Stuttering Severity Chart _____________________________________________________________________________

Downloadable from https://www.uts.edu.au/asrc/resources/oakville-program



___________________________________

References ___________________________________

1 Onslow, M., Webber, M., Harrison, E., Arnott, S., Bridgman, K., Carey, B., Sheedy, S., O’Brian, S., MacMillan, V., & Lloyd, W. (2020). The Lidcombe Program treatment guide. Retrieved from https://www.uts.edu.au/asrc/resources/lidcombe-program

2 Packman, A. (2012). Theory and therapy in stuttering: A complex relationship. Journal of Fluency Disorders, 37, 225–233.

3 Andrews, C., O’Brian, S., Harrison, E., Onslow, M., Packman, A., & Menzies, R. (2012). Syllable-timed speech treatment for school-age children who stutter: A phase I trial. Language, Speech, and Hearing Services in Schools, 43, 359–369.

4 Andrews, C., O’Brian, S., Onslow, M., Packman, A., Menzies, R., & Lowe, R. (2016). Phase II trial of syllable-timed speech treatment for school-age children who stutter. Journal of Fluency Disorders, 48, 44–55.

5 Onslow, M., Andrews, C., & Costa, L. (1990). Parental severity scaling of early stuttered speech: Four case studies. Australian Journal of Human Communication Disorders, 18, 47–61.

6 Teesson, K., Packman, A., & Onslow, M. (2003). The Lidcombe behavioral data language of stuttering. Journal of Speech, Language, and Hearing Research, 46, 1009–1015.

7 Ingham, R. J. (1980). Modification of maintenance and generalization during stuttering treatment. Journal of Speech and Hearing Research, 23, 732–745.

8 Trajkovski, N., O'Brian, S., Onslow, M., Packman, R., Lowe, R., Menzies, R., Jones, & M., Reilly, S. (2019). A three-arm randomized controlled trial of Lidcombe Program and Westmead Program early stuttering interventions. Journal of Fluency Disorders, 61, 105708.

https://www.uts.edu.au/asrc/resources/lidcombe-program

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